CERTIFICATED STAFF APPLICATION

CERTIFICATED STAFF APPLICATION

BON HOMME SCHOOL DISTRICT 4-2

District Office, Box 28, 1404 Fir Street, Tyndall, SD 57066

Name________________________________ __________________________ ___________

Last First M.I.

Social Security Number __________________ Name as it is on Card _____________________

Positions for which you are applying ________________________________________________

If we request an interview, when would be most convenient? ____________________________

Present Address _____________________City_______________ State_______ ZIP________

At This Address Until _________ Home Telephone (____) __________ Best time to call_____

Place of Employment ___________________ May we contact you at work? ____Yes ____No

Work Telephone (___)__________________ Best time to call________________________

Permanent Address ___________________City______________ State _______ ZIP_________

At This Address Until ____________ Home Telephone ( )________ Best time to call ______

Teaching Certificate: Number ____________________________ Expiration Date: ____________________

Endorsement(s) ________________________________________ Teaching Majors: ___________________

Additional Subject/Assignments _____________________________________________________________

If you do not have a certificate, will you by September 1 ______ Yes ______ No

List co-curricular activities you may be interested in directing ______________________________________

Are you currently under contract with another school district? ______Yes ______No

If yes, expiration date: __________ May we contact your present employers? ______Yes ______No

Have you previously applied in Bon Homme 4-2? _____Yes _____No If yes, date:___________

Were you previously employed in Bon Homme 4-2? _____Yes _____No If yes, date:_________

Have you been convicted of a CRIME in the last 7 years? _____Yes _____No

If yes, please explain: ___________________________________________________________________________

BH 4-2 requires and pays for a background check (including fingerprinting) through DCI for all new employees immediately after hiring.

Do you have any past or current physical or mental health conditions which may affect the performance of your work? _____Yes _____No If yes, please explain:

Physical Health _______________________________________________________________________________

____________________________________________________________________________________________

Mental Health ________________________________________________________________________________

____________________________________________________________________________________________

BH 4-2 requires and pays for a physical (including a Urine Analysis) at BH Family Practice for all new employees immediately after hiring.

Are you a US citizen? _____Yes _____No If no, do you have a Green Card? _____Yes _____No

Have you ever served in the United States Armed Forces? _____Yes _____No If yes, indicate branch and discharge date _________________________. Males born after December 31, 1959, are required to register for Selective Service. Are you registered?______Yes ______No

List information regarding your interests, abilities, activities, experience, etc. which you feel have a bearing on your qualifications for this position.

____________________________________________________________________________________________

Write a statement about why you are interested in teaching in BH School District 4-2.

____________________________________________________________________________________________

Briefly state your personal philosophy of education.

______________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________

To the Applicant:

A complete application includes a letter of application, resume, credentials, transcripts and a copy of your South Dakota Teaching Certificate (if available). Your resume should include references (including student teaching), education and work experience. It if does not, please list on a separate sheet of paper and attach to this application form. If your credentials do not include a recommendation from your immediate supervisor or cooperating teacher, please have that individual send a letter of recommendation.

We appreciate sincerely the time and interest you have given in making application to the Bon Homme School District. We assure you that your application will receive prompt consideration.

Bon Homme School District is an equal opportunity employer. The Bon Homme School District does not discriminate against any employee on the basis of sex, race, religion, national origin, age, height, weight, marital status or handicap/disability unrelated to the employee’s ability to perform his/her job.

I verify that the information given by me in this application is true, accurate and complete. I understand that if I have given any false information on this application or if I have omitted any material fact, I may be disqualified from employment with Bon Homme School District, or if hired, I may be discharged upon discovery of such false statement(s) or omission(s). I understand that my employment with Bon Homme School District may be subject to a reference/background check. I hereby authorize Bon Homme School District to investigate the truthfulness of all statements made on this application and/or contact my former employer(s)and other listed reference(s) or any other person(s) who can verify any information submitted to Bon Homme School District in support of my application for employment. I hereby waive any right that I may have against any person contact by Bon Homme School District, including former employers who provide information concerning this application and I release each said person from liability for providing information.

________________________________________ ______________

Signature Date

EMPLOYMENT DATA RECORD

Employees are treated during employment without regard to race, color, religion, sex, national origin, age, marital status or veteran status, medical condition or handicap or any other legally protected status. As an Equal Opportunity Employer, we comply with government regulations.

The purpose for this Data Record is to comply with government record keeping, reporting and other legal requirements. Periodic reports are made to the government on the following information. The completion of this Data Record is optional. If you choose to volunteer the requested information, please note that all Data Records are kept in a Confidential File and are not a part of your Job Application or personnel file.

Please note: Your cooperation is voluntary. Inclusion or exclusion of any data will not affect any employment decision.

VOLUNTARY SURVEY

Please Print Date ________________________

Name__________________________________________________________________

Last First M.I.

Street Address/P.O. Box___________________________________________________

City________________________________ State____________ ZIP_____________

Social Security Number____________________________________________________

Current Job ______________________________________________________________

Check One: _____ Male _____ Female

Age______________

Check One Of The Following (Ethnic Origin):

_____White _____ Hispanic _____ American Indian/Alaskan Native

_____Black _____ Other _____ Asian/Pacific Islander

Check If Any Of The Following Are Applicable:_____Vietnam Era Veteran

_____Disabled Veteran _____Handicapped Individual

OFFICE USE ONLY

Position(s) applied for is open:_____ Yes _____ No

Position(s) considered for: __________________________________________

Date(s)_________________________________________________________